clinical decision support anomalies

CDS alert malfunctions are frequent. The empirically derived taxonomy formalizes the common recurring issues that cause these malfunctions, helping CDS developers anticipate and prevent CDS malfunctions before they occur or detect and resolve them expediently.

Developing effective and reliable rule-based clinical decision support (CDS) alerts and reminders is challenging. Using a previously developed taxonomy for alert malfunctions, we identified best practices for developing, testing, implementing, and maintaining alerts and avoiding malfunctions.

We identified and investigated several CDSS malfunctions at Brigham and Women’s Hospital and present them as a case series. We also conducted a preliminary survey of Chief Medical Information Officers to assess the frequency of such malfunctions.